Rationale: High levels of preventable infection still occur among mother and newborns. This burden is concentrated in low and middle-income countries (LMICs) where increasing numbers of women attend facilities for childbirth. Poor quality of care contributes to this burden. Birth attendants’ hand hygiene in healthcare facilities is a key infection prevention opportunity. Objectives and methods: To assess existing evidence on birth attendants’ hand hygiene compliance in LMIC facilities by systematically reviewing the literature. To describe the enabling environment for hand hygiene in Zanzibar maternity wards (Tanzania) using a mixed-methods cross-sectional survey. To develop a tool to capture the complex patterns of hand hygiene performed by birth attendants using time-&- motion methods. To assess the compliance of Zanzibar birth attendants to hand rubbing/washing, avoiding recontamination and glove use before aseptic procedures using time-&-motion methods and descriptive statistics. To assess the determinants of Zanzibar birth attendants’ hand rubbing/washing and of avoiding recontamination before aseptic procedures using time-&-motion, a survey, and analytical methods. Findings: We found only nine studies – often with poor methods and definitions – that quantitatively examine birth attendants’ hand hygiene in LMICs facilities; amongst the three with better definitions and sample sizes, compliance ranged from 1-28%. The HANDS at birth tool was developed using time-&-motion software, which allowed all birth attendants’ actions to be captured and operationalised. Only 9.6% of Zanzibar birth attendants hand rubbed/washed, donned gloves and avoided recontamination before aseptic procedures. Half of the time when rubbing/washing or glove donning was performed, hands were recontaminated. Analysis of determinants found rubbing/washing was associated with lower workload (Adjusted Odds Ratio= 29.39), and availability of single-use drying material (AOR=2.9). Avoiding glove recontamination was associated with less time elapsed since glove donning (AOR=4.49). Conclusion: Further research should examine the extent to which failure to avoid recontamination contributes to poor hand hygiene and what effective behaviour change strategies could tackle it.